Helen B. Murray

Re-examining premature mortality in anorexia nervosa: a meta-analysis redux.

Anorexia nervosa (AN) is reported to have the highest premature mortality of any psychiatric disorder, but recent meta-analyses may have inflated estimates. We sought to re-estimate mortality after methodological corrections and to identify predictors of mortality. We included 41 cohorts from 40 peer-reviewed studies published between 1966 and 2010. Methods included double data extraction, log-linear regression with an over-dispersed Poisson model, and all-cause and suicide-specific standardized mortality ratios (SMRs), with 95% Poisson confidence intervals. Participants with AN were 5.2 [3.7-7.5] times more likely to die prematurely from any cause, and 18.1 [11.5-28.7] times more likely to die by suicide than 15-34 year old females in the general population. Our estimates were 10% and 49% lower, respectively, than previously reported SMRs. Risk of premature mortality was highest in studies with older participants, although confounding by treatment was present. Gender, ascertainment, and diagnostic criteria also impacted risk.

Prevalence of DSM-5 avoidant/restrictive food intake disorder in a pediatric gastroenterology healthcare network

OBJECTIVE Few published studies have evaluated the clinical utility of new diagnostic criteria for avoidant/restrictive food intake disorder (ARFID), a DSM-5 reformulation of feeding and eating disorder of infancy or early childhood. We examined the prevalence of ARFID and inter-rater reliability of its diagnostic criteria in a pediatric gastrointestinal sample. METHOD We conducted a retrospective chart review of 2,231 consecutive new referrals (ages 8-18 years) to 19 Boston-area pediatric gastroenterology clinics for evidence of DSM-5 ARFID. RESULTS We identified 33 (1.5%) ARFID cases; 22 of whom (67%) were male. Most were characterized by insufficient intake/little interest in feeding (n = 19) or limited diet due to sensory features of the food (n = 7). An additional 54 cases (2.4%) met one or more ARFID criteria but there was insufficient information in the medical record to confer or exclude the diagnosis. Diagnostic agreement between coders was adequate (κ = 0.72). Common challenges were (i) distinguishing between diagnoses of ARFID and anorexia nervosa or anxiety disorders; (ii) determination of whether the severity of the eating/feeding disturbance was sufficient to warrant diagnosis in the presence of another medical or psychiatric disorder; and (iii) assessment of psychosocial impairment related to eating/feeding problems. DISCUSSION In a pediatric treatment-seeking sample where ARFID features were common, cases meeting full criteria were rare, suggesting that the diagnosis is not over-inclusive even in a population where eating/feeding difficulties are expected.

Recovery From Anorexia Nervosa and Bulimia Nervosa at 22-Year Follow-Up.

OBJECTIVE The course of eating disorders is often protracted, with fewer than half of adults achieving recovery from anorexia nervosa or bulimia nervosa. Some argue for palliative management when duration exceeds a decade, yet outcomes beyond 20 years are rarely described. This study investigates early and long-term recovery in the Massachusetts General Hospital Longitudinal Study of Anorexia and Bulimia Nervosa. METHODS Females with DSM-III-R/DSM-IV anorexia nervosa or bulimia nervosa were assessed at 9 and at 20 to 25 years of follow-up (mean [SD] = 22.10 [1.10] years; study initiated in 1987, last follow-up conducted in 2013) via structured clinical interview (Longitudinal Interval Follow-Up Evaluation of Eating Disorders [LIFE-EAT-II]). Seventy-seven percent of the original cohort was re-interviewed, and multiple imputation was used to include all surviving participants from the original cohort (N = 228). Kaplan-Meier curves estimated recovery by 9-year follow-up, and McNemar test examined concordance between recovery at 9-year and 22-year follow-up. RESULTS At 22-year follow-up, 62.8% of participants with anorexia nervosa and 68.2% of participants with bulimia nervosa recovered, compared to 31.4% of participants with anorexia nervosa and 68.2% of participants with bulimia nervosa by 9-year follow-up. Approximately half of those with anorexia nervosa who had not recovered by 9 years progressed to recovery at 22 years. Early recovery was associated with increased likelihood of long-term recovery in anorexia nervosa (odds ratio [OR] = 10.5; 95% CI, 3.77-29.28; McNemar χ²₁ = 31.39; P < .01) but not in bulimia nervosa (OR = 1.0; 95% CI, 0.49-2.05; McNemar χ²₁ = 0; P = 1.0). CONCLUSION At 22 years, approximately two-thirds of females with anorexia nervosa and bulimia nervosa were recovered. Recovery from bulimia nervosa happened earlier, but recovery from anorexia nervosa continued over the long term, arguing against the implementation of palliative care for most individuals with eating disorders.

The impact of revised DSM-5 criteria on the relative distribution and inter-rater reliability of eating disorder diagnoses in a residential treatment setting

This study evaluated the relative distribution and inter-rater reliability of revised DSM-5 criteria for eating disorders in a residential treatment program. Consecutive adolescent and young adult females (N=150) admitted to a residential eating disorder treatment facility were assigned both DSM-IV and DSM-5 diagnoses by a clinician (n=14) via routine clinical interview and a research assessor (n=4) via structured interview. We compared the frequency of diagnostic assignments under each taxonomy and by type of assessor. We evaluated concordance between clinician and researcher assignment through inter-rater reliability kappa and percent agreement. Significantly fewer patients received either clinician or researcher diagnoses of a residual eating disorder under DSM-5 (clinician-12.0%; researcher-31.3%) versus DSM-IV (clinician-28.7%; researcher-59.3%), with the majority of reassigned DSM-IV residual cases reclassified as DSM-5 anorexia nervosa. Researcher and clinician diagnoses showed moderate inter-rater reliability under DSM-IV (κ=.48) and DSM-5 (κ=.57), though agreement for specific DSM-5 other specified feeding or eating disorder (OSFED) presentations was poor (κ=.05). DSM-5 revisions were associated with significantly less frequent residual eating disorder diagnoses, but not with reduced inter-rater reliability. Findings support specific dimensions of clinical utility for revised DSM-5 criteria for eating disorders.

Pica and rumination behavior among individuals seeking treatment for eating disorders or obesity

OBJECTIVE Pica and rumination disorder (RD)-formerly classified within DSM-IV Feeding and Eating Disorders of Infancy or Early Childhood-are now classified within DSM-5 Feeding and Eating Disorders. Though pica and RD have been studied in select populations (e.g., pregnant women, intellectually disabled persons), their typical features and overall prevalence remain unknown. This study examined the clinical characteristics and frequency of DSM-5 pica and RD among individuals seeking treatment for eating disorders and obesity. METHOD We conducted structured interviews with adolescent and young adult females from a residential eating disorder center (N = 149), and adult males and females with overweight or obesity from an outpatient weight-loss clinic (N = 100). RESULTS Several participants reported ingesting non-nutritive substances (e.g., ice) for weight-control purposes. However, only 1.3% (n = 2; 95% CI: .06% to 5.1%) at the residential eating disorder center and 0% at the weight-loss clinic met DSM-5 criteria for pica, consuming gum and plastic. Although no eating disorder participants were eligible for an RD diagnosis due to DSM-5 trumping rules, 7.4% (n = 11; 95% CI: 4.0% to 12.9%) endorsed rumination behavior under varying degrees of volitional control. At the weight-loss clinic, 2.0% (n = 2; 95% CI: 0.1% to 7.4%) had RD. DISCUSSION DSM-5 pica and RD were rare in our sample of individuals seeking treatment for eating disorders and obesity, but related behaviors were more common. The wide range of pica and rumination presentations highlights the challenges of differential diagnosis with other forms of disordered eating.

Do DSM-5 Eating Disorder Criteria Overpathologize Normative Eating Patterns among Individuals with Obesity?

Background. DSM-5 revisions have been criticized in the popular press for overpathologizing normative eating patterns—particularly among individuals with obesity. To evaluate the evidence for this and other DSM-5 critiques, we compared the point prevalence and interrater reliability of DSM-IV versus DSM-5 eating disorders (EDs) among adults seeking weight-loss treatment. Method. Clinicians (n = 2) assigned DSM-IV and DSM-5 ED diagnoses to 100 participants via routine clinical interview. Research assessors (n = 3) independently conferred ED diagnoses via Structured Clinical Interview for DSM-IV and a DSM-5 checklist. Results. Research assessors diagnosed a similar proportion of participants with EDs under DSM-IV (29%) versus DSM-5 (32%). DSM-5 research diagnoses included binge eating disorder (9%), bulimia nervosa (2%), subthreshold binge eating disorder (5%), subthreshold bulimia nervosa (2%), purging disorder (1%), night eating syndrome (6%), and other (7%). Interrater reliability between clinicians and research assessors was “substantial” for both DSM-IV (κ = 0.64, 84% agreement) and DSM-5 (κ = 0.63, 83% agreement). Conclusion. DSM-5 ED criteria can be reliably applied in an obesity treatment setting and appear to yield an overall ED point prevalence comparable to DSM-IV.

Cognitive-behavioral treatment of adult rumination behavior in the setting of disordered eating: A single case experimental design.

The integration of feeding and eating disorders into a single DSM-5 chapter introduces an opportunity to explore common mechanisms and transdiagnostic treatment approaches. In contrast to a robust literature on the evidence-based treatment of eating disorders, very few data guide the treatment of rumination disorder (RD). In a single case experimental design, we describe the treatment of a 27-year-old woman who presented to an eating-disorder clinic with a 15-year history of untreated rumination and intermittent binge eating. According to time series analysis, she reduced rumination frequency at trend-level during the initial baseline phase (self-monitoring only), and exhibited significant reductions during the active intervention phase (self-monitoring + cognitive-behavioral techniques including diaphragmatic breathing and behavioral experimentation). She maintained these gains at 23 weeks post-intervention. Although more rigorous systematic investigation is needed, these data suggest that selected cognitive and behavioral techniques already familiar to eating-disorder clinicians may have heuristic value for RD treatment.

Predictors of long-term recovery in anorexia nervosa and bulimia nervosa: Data from a 22-year longitudinal study

OBJECTIVE The objective of this study was to investigate predictors of long-term recovery from eating disorders 22 years after entry into a longitudinal study. METHOD One hundred and seventy-six of the 228 surviving participants (77.2%) were re-interviewed 20-25 years after study entry using the Longitudinal Interval Follow-up Evaluation to assess ED recovery. The sample consisted of 100 women diagnosed with anorexia nervosa (AN) and 76 with bulimia nervosa (BN) at study entry. RESULTS A comorbid diagnosis of major depression at the start of the study strongly predicted having a diagnosis of AN-Restricting type at the 22-year assessment. A higher body mass index (BMI) at study intake decreased the odds of being diagnosed with AN-Binge Purge type, relative to being recovered, 22 years later. The only predictor that increased the likelihood of having a diagnosis of BN at the 22-year assessment was the length of time during the study when the diagnostic criteria for BN were met. CONCLUSIONS Together, these results indicate that the presence and persistence of binge eating and purging behaviors were poor prognostic indicators and that comorbidity with depression is particularly pernicious in AN. Treatment providers might pay particular attention to these issues in an effort to positively influence recovery over the long-term.

Prevalence in primary school youth of pica and rumination behavior: The understudied feeding disorders: MURRAY et al.

OBJECTIVE Little epidemiological evidence exists on rumination disorder behavior (RB) and pica behavior (PB). We examined prevalence of RB and PB and presence of comorbid feeding/eating disorder symptoms among school-aged children. METHOD In elementary schools in Switzerland, 1,430 children (54.0% female) ages 7-13 completed the Eating Disorder Examination-Questionnaire for children (ChEDE-Q) and the Eating Disturbances in Youth Questionnaire (EDY-Q). RESULTS EDY-Q behavior frequency showed 9.7% reported RB only, 10.0% reported PB only, and 3.1% reported RB + PB (≥1 on 0-6 Likert scale). At a clinical cut-off score of ≥ 4, 1.7% had RB only, 3.8% had PB only, and 1.1% had RB + PB. Avoidant/restrictive food intake disorder symptoms were most common in those with RB + PB, and more common in those with RB or PB than those without. The degree of eating disorder symptoms (by ChEDE-Q) over the past 28 days were similar among those with RB, PB, or RB + PB, but less common in those without RB or PB. DISCUSSION RB and PB were commonly reported in our sample of school-aged children, even at a potential clinically significant cut-off. Our findings also suggest that the degree of eating disorder symptom comorbidity is similar between those with RB and PB.

Gender differences in eating disorder psychopathology across DSM-5 severity categories of anorexia nervosa and bulimia nervosa

OBJECTIVE This study examined whether patterns of eating-disorder (ED) psychopathology differed by gender across DSM-5 severity specifiers in anorexia nervosa (AN) and bulimia nervosa (BN). METHOD We tested whether ED psychopathology differed across DSM-5 severity specifiers among 532 adults (76% female) in a residential treatment center with AN or BN. We hypothesized that severity of ED psychopathology would increase in tandem with increasing severity classifications for both males and females with AN and BN. RESULTS Among females with BN, DSM-5 severity categories were significantly associated with increasing ED psychopathology, including Eating Disorder Examination-Questionnaire dietary restraint, eating concern, shape concern, and weight concern; and Eating Disorder Inventory drive for thinness and bulimia. ED psychopathology did not differ across DSM-5 severity levels for males with BN. For both males and females with AN, there were no differences in ED psychopathology across severity levels. DISCUSSION Results demonstrate that DSM-5 severity specifiers may function differently for males versus females with BN. Taken together, data suggest DSM-5 severity specifiers may not adequately capture severity, as intended, for males with BN and all with AN. Future research should evaluate additional clinical validators of DSM-5 severity categories (e.g., chronicity, treatment non-response), and consider alternate classification schemes.